難復位性股骨頸骨折的概念提出與治療李智勇張奇陳偉劉月駒許斌張英澤[摘要]目的提出難復位性股骨頸骨折的概念，并探討其分型與治療方法。方法對2006年1月至2008年12月收治的519例移位型股骨頸骨折患者進行前瞻性研究，男241例，女278例；年齡21?66歲，平均54.9歲；左側295例，右側224例。所有患者首先嘗試牽引閉合復位，若經(jīng)3次整復骨折不能達到理想復位效果，則認為屬于難復位性股骨頸骨折，改用股骨頭干三維互動復位技術復位，并采用3枚空心釘固定。分析難復位性股骨頸骨折的特點并對其進行分型，評價股骨頭干三維互動復位技術的臨床療效。結果共有31例(6.0%)難復位性股骨頸骨折，男20例，女11例；年齡21?58歲，平均39.6歲；均為GardenW型骨折。均采用股骨頭干三維互動復位技術復位成功，28例骨折復位質量^Garden指數(shù)I級，3例達Garden指數(shù)II級。根據(jù)X線片及CT影像學特點，難復位性股骨頸骨折可分為3型：1型5例(16.1%)：骨折線為斜形，近端骨折片呈“鷹嘴”狀嵌插入骨折遠端；II型17例(54.8%)：骨折線不規(guī)則，骨折遠端外旋并嵌插入近端；III型9例(29.0%)：骨折端完全移位，股骨頭和股骨干之間有分離，股骨頭成漂浮狀態(tài)，旋轉移位較大。29例患者術后獲2?4年(平均3.3年)隨訪，骨折均獲骨性愈合，愈合時間為16?24周(平均20.1周)。3例發(fā)生股骨頭壞死，其中II型l例，I型2例。結論難復位性股骨頸骨折可分為3型，采用股骨頭干三維互動復位技術復位、3枚空心釘固定可獲得較好的臨床療效。股骨頸骨折；分型；復位ClassificationandtreatmentofirreduciblefemoralneckfracturesLIZhi-yongZHANGQiCHENWeiTheInstituteofOrthopaedics,TheThirdAffiliatedHospital,HebeiMedicalUniversity,Shijiazhuang050051,China[Abstract]ObjectiveToexploretheclassificationandtreatmentmethodsoffemoralneckfractureswhicharedifficulttoreduce.MethodsThepresentstudyenrolled519patientswithdisplacedfemoralneckfractureswhohadbeentreatedfromJanuary2006toDecember2008inourinstitute.Theywere241menand278women,withameanageof54.9years(from21to66years).Thelefthipjointwasinvolvedin295casesandtherightin224cases.Ifafracturefailedtoobtainsatisfactoryrepositionafterwetriedclosedreductionfor3times,itwasdefinedasanirreduciblefemoralneckfracturewhichwasnextreducedbyourself-designedtechniquecalled"3-Dinterreactionreduction"beforeitwasfixedby3cannulatedscrews.Theirreduciblefemoralneckfractureswerecharacterizedandtheclinicalefficacyof"3-Dinterreactionreduction"wasevaluated.ResultsInthisgroup,31casesofirreduciblefemoralneckfractureweredefinedandsuccessfullyreducedbythe"3-Dinterreactionreduction"technique.Ofthem,28casesobtainedreductionofGardenGradeIand3casesofGardenGradeII.Theirreduciblefemoralneckfractureswereclassifiedinto3typesaccordingtotheirradiologicalfeatures.IntypeI(5cases,16.I%),thefracturelinewasobliqueandanolecranon-shapedproximalfragmentintrudedintothedistantfractureend.IntypeII(17cases,54.8%),thefracturelinewasirregularandtheoutward-rotateddistantfractureendintrudedintotheproximalfractureend.IntypeIII(9cases,29.0%),thefractureendswerecompletelydisplacedandthefloatingfemoralheadwasdisconnectedwiththeshaft.Ofthepatientswithirreduciblefemoralneckfracture,29werefollowedupfor2to4years(average,3.3years).Boneunionwasachievedinallthe29casesafteranaverageof20.1weeks(from16to24weeks).Ofthem,3casesdevelopednecrosisoffemoralhead,oneoftypeIIand2oftypeIIIbyourclassification.ConclusionsIrreduciblefemoralneckfracturescanbeclassifiedinto3types."3-Dinterreactionreduction"andfixationwith3cannulatedscrewscanbeafinestrategytotreatthem.Femoralneckfractures;Classification;Reduction10.3760/cma.j.issn.1671-7600.2011.11.005050051石家莊，河北醫(yī)科大學第三醫(yī)院骨科研究所-1021"?1022"@@[1]李欣，陳仲，楊洪昌.股骨頸骨折閉合復位的實際效果分析.中華創(chuàng)傷骨科雜志，2011,13:25-28.@@[2]ParkerMJ,RaghavanR,GurusamyK.Incidenceoffracture-healingcomplicationsafterfemoralneckfractures.ClinOrthopRelatRes,2007(458):175-179.@@[3]GardenRS.Malreductionandavascularnecrosisinsubcapitalfracturesofthefemur.JBoneJointSurgBr,1971,53:183-197.@@[4]DavidovitchRI,JordanCJ,EgolKA,etal.Challengesinthetreatmentoffemoralneckfracturesinthenonelderlyadult.JTrauma,2010,68:236-242.@@[5]BarnesB,DunovanK.Functionaloutcomesafterhipfracture.PhysTher,1987,67:1675-1679.@@[6]張英澤，張奇，李寶俊，等.股骨頭干互動三維閉合復位技術治療難復型股骨頸骨折.河北醫(yī)科大學學報，2009,30:70-71，插5.@@[7]SchepNW,HeintjesRJ,MartensEP,etal.Retrospectiveanalysisoffactorsinfluencingtheoperativeresultafterpercutaneousosteosynthesisofintracapsularfemoralneckfractures.Injury,2004,35:1003-1009.@@[8]RehnbergL,OlerudC.Thestabilityoffemoralneckfracturesanditsinfluenceonhealing.JBoneJointSurgBr,1989,71:173-177.@@[9]劉粵，張長青，孟煒.閉合復位空心釘治療中老年股骨頸骨折后股骨頭壞死的多元相關研究.中華創(chuàng)傷骨科雜志，2006,8：617-621.@@[10]危杰，毛玉江，賈正中.中空加壓螺絲釘治療新鮮股骨頸骨折212例.中華創(chuàng)傷雜志，2000，16:142-144.@@[11]BhandariM,TornettaP3rd,HansonB,etal.Optimalinternalfixationforfemoralneckfractures:multiplescrewsorslidinghipscrews?JOrthopTra